Exam 1 OB NCLEX

a nurse is caring for a postpartum mom who delivered her third infant 2 days ago, the nurse recognizes that which of the following findings are suggestive of postpartum depression

fatigue, insomnia, flat affect

the nurse is caring for a client who is postpartum, the nurse sure should ID which of the following findings as an early indicator of hypovolemia caused by hemorrhage

increasing pulse and decreasing BP

A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be:

"Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding."

A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select all that apply.1. Grasp the baby's thighs with the thumbs on the inner thighs and forefingers on the outer thighs.2. Gently adduct the baby's thighs.3. Palpate the trochanter to sense changes during hip rotation.4. Place the baby in a prone position.5. Flex the baby's hips and knees at 90º angles.

1,3,5

The nursery charge nurse is assessing a 1-day-old female on morning rounds.Which of the following findings should be reported to the neonatalogist as soon as possible?1. Blood in the diaper.2. Grunting during expiration.3. Deep red coloring on one side of the body with pale pink on the other side.4. Lacy and mottled appearance over the entire chest and abdomen.

2

15. A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis.Which of the following actions demonstrates that the mother has learned the information?1. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide.2. The mother covers the glans with antifungal ointment after rinsing off anydischarge.3. The mother squeezes soapy water from the wash cloth over the glans.4. The mother replaces the dry sterile dressing before putting on the diaper.

3

A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate?1. Place child in isolette. 2. Administer oxygen.3. Swaddle baby in blanket.4. Apply pulse oximeter.

3

a newborn was not dried completely after birth, what mechanism causes heat loss

evaporation

A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate?

document the findings

The mother notes that her baby has a "bulge" on the back of one side of the head.She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following?1. Molding of the baby's skull so that the baby could fit through her pelvis.2. Swelling of the tissues of the baby's head from the pressure of her pushing.3. The position that the baby took in her pelvis during the last trimester of her pregnancy.4. Small blood vessels that broke under the baby's scalp during birth.

4

A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following needles could the nurse safely choose for the injection?1. 5⁄8 inch, 18 gauge.2. 5⁄8 inch, 25 gauge.3. 1 inch, 18 gauge.4. 1 inch, 25 gauge.

as small as possible

While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?

Do nothing because acrocyanosis is normal in the neonate

A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate?

The baby has lost less than 4% of its birth weight. The normal weight loss for babies is 5% to 10%.

The slight overlapping of the cranial bones or shaping of the fetal head during labor is called?a. molding b. lightening c. furguson's reflex d. Valsava Maneuver

a

When assess a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective is:a. dilation of the cervix b. decent of the fetus c. increase in bloody show d, rupture of the amniotic membranes

a

During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a RN finds the clients uterus to be firm and midline & at the level of the umbilicus. The nurse interprets this finding as

a normal postural discharge of lochia

a nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding, the client reports breast engorgement, which recommendations should the nurse make

apply cold compresses between feedings

When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia?

bradycardia

The nurse recognizes that a woman is in true labor when she states:a. my baby dropped and i have to urinate more frequently now b. my water just broke c. the contractions in my uterus are getting stronger and more close together nowD. I passes some thick, pink mucus when i urinated this morning

c

a nurse on the postpartum unit is performing a physical assessment of a client who is being admitted with a suspected DVT, what findings should she suspect

calf tenderness to palpation, elevated temp, area of warmth

a nurse is caring for a patient 1 hour postpartum following a vaginal birth and is experiencing uncontrollable shaking, the nurse should understand that the shaking is due to which of the following factors

change in body fluids and metabolic effort of labor

a nurse is assessing a client who has postpartum depression, which findings should she suspect

concerns to pay bills, anxiety about assuming a new role as a mother, rapid decline in estrogen and progesterone, feeling of inadequacy with the new role as a mother

When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority?

cover neonates head with a cap

a nurse is caring for a newborn immediately following birth, what is the priority intervention

covering newborns head with a cap

Regarding how the fetus moves through the birth canal, nurses should be aware that:a. the transverse lie is preferred for vaginal birth b. the fetal attitude describes the angle at which the fetus exits the uterus c. of the 2 primary fetal lies, the horizontal lie is that in which the long axis of the fetus is parallel to the long axis of the mother.D. the normal attitude of the fetus is called general flexion

d

The nurse expects to see which maternal cardiovascular finding during labor?a. decreased BPb. Dereased Pulsec. Decreased WBCd. Increased Cardiac Output

d

When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called the fetal ___.A. PositionB. PresentationC. LieD. Attitude

d

The nurse is aware that a healthy newborn's respirations are:

irregular, abdominal, shallow, 30-60 per minute

When teaching umbilical cord care to a new mother, the nurse would include which information?

keep the cord dry and open to air

a nurse is providing discharge teaching to a postpartum client following a C section, the client reports leaking urine every time she sneezes or coughs, which interventions should the nurse suggest

kegal exercises

A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as:

milia

fundal assessment on a client who is 2 days postpartum and observes the pad for lochia, she finds the pad to be saturated 12 cm with lochia that is bright red and contains small clots, what findings should be documented

moderate lochia rubra

a nurse is completing an assessment, which of the following data indicate the newborn is adapting to extrauterine life

obligatory nose breathing and apnea for 10 second periods

Please put an "X" on the site where the nurse should perform a heel stick on the neonate.

outer or inner aspect of the heel

after gomco circumcision the penis is covered with

petroleum gauze

17. The nurse is teaching a mother regarding the baby's sutures and fontanelles. Pleaseput an "X" on the fontanelle that will close at 6 to 8 weeks of age.

posterior

A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition?

swelling of tissue over the presenting part of the head

a nurse is teaching a new licensed nurse how to bathe a newborn and observes a bluish marking across the lower back, the nurse should include which teaching

this is frequently seen in newborns with darker skin

16. Please put an "X" on the site where the nurse should administer vitamin K 0.5 mgIM to the neonate.

vastus lateralis

Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site?

vastus lateralis

A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding?

vernix